Program management (1 - 10 of 126 items)
Medicare: Claim Review Programs Could Be Improved with Additional Prepayment Reviews and Better Data
GAO-16-394: Published: Apr 13, 2016. Publicly Released: May 13, 2016.
The Centers for Medicare & Medicaid Services (CMS) uses different types of contractors to conduct prepayment and postpayment reviews of Medicare fee-for-service claims at high risk for improper payments. Medicare Administrative Contractors (MAC) conduct prepayment and postpayment reviews; Recovery Auditors (RA) generally conduct postpayment reviews; and the Supplemental Medical Review Contractor (...
Medicaid and CHIP: Increased Funding in U.S. Territories Merits Improved Program Integrity Efforts
GAO-16-324: Published: Apr 8, 2016. Publicly Released: May 9, 2016.
Eligibility and benefits for Medicaid and the state Children's Health Insurance Program (CHIP) in five U.S. territories—American Samoa, Commonwealth of the Northern Mariana Islands (CNMI), Guam, Puerto Rico and the U. S. Virgin Islands—differ from one another and from the states, generally reflecting the territories' unique circumstances. For example, Guam is the only territory that covers all...
Medicaid Program Integrity: Improved Guidance Needed to Better Support Efforts to Screen Managed Care Providers
GAO-16-402: Published: Apr 22, 2016. Publicly Released: May 6, 2016.
GAO found that the selected states and Medicaid managed care plans face significant challenges in screening providers for eligibility to participate in the Medicaid program. Based on information we received from two selected states and 16 selected plans, GAO found that the states and plans used information that was fragmented across 22 databases managed by 15 different federal agencies to screen p...
Private Health Insurance: Federal Oversight Premiums and Enrollment for Consumer Operated and Oriented Plans in 2015
GAO-16-326: Published: Mar 10, 2016. Publicly Released: Mar 17, 2016.
The Centers for Medicare & Medicaid Services' (CMS) monitoring of the consumer governed, nonprofit health insurance issuers—known as consumer operated and oriented plans (CO-OPs)—evolved as the CO-OP program matured, and as 12 of the 23 CO-OPs ceased operations on or before January 1, 2016. CMS's initial monitoring activities, starting when it began to award CO-OP program loans in early 2012,...
Medicaid: Key Issues Facing the Program
GAO-15-677: Published: Jul 30, 2015. Publicly Released: Jul 30, 2015.
GAO identified four key issues facing the Medicaid program, based on prior work.Access to care : Medicaid enrollees report access to care that is generally comparable to that of privately insured individuals and better than that of uninsured individuals, but may have greater health care needs and greater difficulty accessing specialty and dental care.Transparency and oversight : The lack of comple...
Medicaid Information Technology: CMS Supports Use of Program Integrity Systems but Should Require States to Determine Effectiveness
GAO-15-207: Published: Jan 30, 2015. Publicly Released: Mar 2, 2015.
In the 10 selected states reviewed, GAO found the use of varying types of information technology (IT) systems to support efforts to prevent and detect improper payments. All 10 states had implemented a Medicaid Management Information System (MMIS) to process claims and support their program integrity efforts, and 7 had implemented additional types of systems to meet specific needs. Three states we...
Vaccine Injury Compensation: Most Claims Took Multiple Years and Many Were Settled through Negotiation
GAO-15-142: Published: Nov 21, 2014. Publicly Released: Nov 21, 2014.
Most of more than 9,800 claims filed with the National Vaccine Injury Compensation Program (VICP) since fiscal year 1999 have taken multiple years to adjudicate (see fig.). More than 1,000 (11 percent) of claims filed since fiscal year 1999 were still in process (pending) as of March 31, 2014; most of these were pending for 2 years or less. A greater percentage of the claims filed since fiscal yea...
Medicaid Program Integrity: Increased Oversight Needed to Ensure Integrity of Growing Managed Care Expenditures
GAO-14-341: Published: May 19, 2014. Publicly Released: Jun 18, 2014.
GAO identified a gap in state and federal efforts to ensure Medicaid managed care program integrity. Federal laws require the states and the Centers for Medicare & Medicaid Services (CMS) to ensure the integrity of the Medicaid program, including payments under Medicaid managed care, which are growing at a faster rate than payments under fee-for-service (FFS). However, five state program integrity...
Medicare Fraud: Progress Made, but More Action Needed to Address Medicare Fraud, Waste, and Abuse
GAO-14-560T: Published: Apr 30, 2014. Publicly Released: Apr 30, 2014.
The Centers for Medicare & Medicaid Services (CMS)—the agency within the Department of Health and Human Services (HHS) that oversees Medicare—has made progress in implementing several key strategies GAO identified in prior work as helpful in protecting Medicare from fraud; however, important actions that could help CMS and its program integrity contractors combat fraud remain incomplete.Provid...
Health Resources and Services Administration: Review of Internal Communication Mechanisms, Staffing, and Use of Contracts
GAO-14-52: Published: Dec 3, 2013. Publicly Released: Jan 2, 2014.
The Department of Health and Human Services' (HHS) Health Resources and Services Administration (HRSA) has mechanisms in place to share information important for supporting the agency's mission across its various organizational components and levels of staff--a practice that is consistent with internal control standards for the federal government. These communication methods include an annual oper...